Pasquale J. Accardo

Persistent toe walking in autism.

The records of 954 ambulatory children presenting for initial evaluation to a university developmental pediatrician were reviewed for the prevalence of persistent toe walking and associated tight heel cords. The incidence of persistent toe walking (20.1%) and tight heel cords (12.0%) were found to be higher in 324 children with an autistic spectrum disorder but lower (10.0%/3.0%) in 30 children with Asperger syndrome. These results confirm the previously reported high incidence of toe walking in children with autism and with language disorders and also raise the possibility of a secondary orthopedic deformity that can complicate long-term management of these patients.

Standardization of the Capute Scales: methods and results.

The Capute Scales is a 100-item developmental assessment tool to quantitatively measure expressive and receptive language and nonverbal problem-solving skills in infants from birth to 3 years of age. The present multisite study standardized the instrument on a population of 1055 typically developing children balanced for age, sex, and race and generated normative tables to document the instruments utility. There were no significant performance differences by race or sex. The achieved age levels for individual test items and for total scores were accurately predicted by the age levels assigned to the test items. The conversion of age levels to standard scores was found to be unnecessary because the developmental quotients derived from age ratios did not differ significantly from the derived scores. (J Child Neurol 2004;19:967—972).

Toe Walking in Autism Further Observations

Toe walking has been associated with language disorders and autism. To better understand the association between persistent toe walking and sensory and motor variables in children with autism, the degree of toe walking was compared with an estimate of the severity of sensory integration dysfunction symptoms and the presence of residual components of the tonic labyrinthine in supine reflex pattern in 61 children younger than 37 months of age with newly diagnosed autism. There was no association between the presence of toe walking and sensory symptoms (P = .5298) or language age (P = .6142), but there was an association between toe walking and the presence of components of the tonic labyrinthine reflex (P = .04222). These preliminary results support the contribution of subtle motor deficits to the evolution of some behaviors associated with autism.

Formal Speech-Language Screening Not Shown to Help Children

Confirming its first report from 2006, in this issue of Pediatrics , the US Preventive Services Task Force (USPSTF) continues to find no evidence to suggest that speech-language screening improves speech and language outcomes.1,2 This persistent lack of evidence accumulated across nearly a decade reveals that unlike simple laboratory screening for lead toxicity or dyslipidemia, child development represents a drastically more complex phenomenon that may present insurmountable obstacles to the process of simple screening.nnChild development and screening have conflicting definitions. Child development is defined as the basic science of pediatrics3; it fundamentally distinguishes pediatrics from all other areas of medicine, and developmental disorders are among the most prevalent chronic medical conditions in daily pediatric practice.4 Screening, in contrast, is defined as a process to be carried out by parents (rather than trained professionals), briefly and rapidly, for the purpose of separating children into those probably not in need of further evaluation from those who would probably benefit from more in-depth assessment.5 Different screening tests that have … nnAddress correspondence to Robert G. Voigt, MD, FAAP, Meyer Center for Developmental Pediatrics, Texas Children’s Hospital, 8080 North Stadium Dr, Houston, TX 77054. E-mail: rgvoigt{at}bcm.edu

The Challenge of Cerebral Palsy Classification: The ELGAN Study

erebral palsy (CP) is a group of motor-impairment syndromes secondary to a wide range of genetic and acquired disorders of early brain development. Like he elephant, CP can be variably described based on many haracteristics, including functional impairment, neurologic ndings, etiology, imaging, and topography. The wide range f classification systems, lack of consensus on optimal treatent, and plethora of medical, rehabilitative, and compleentary-alternative approaches to management reflect the tate of the science. Before Part H of Public Law 99-457 (Education of the andicapped Act) funded early intervention services for nfants and toddlers in 1986, it was necessary to establish a iagnosis of CP to provide physical therapy for young chilren with motor impairment. As developmental support serices became more readily available for young children with ven mild motor delays, a formal determination of CP was no onger required to provide eligibility for services. This change as welcomed by families and clinicians alike, with the caveat hat some infants “outgrew” the diagnosis but later manifested ther neurologic disabilities. However, the early identification of CP remains important o evaluate risk factors, early treatment, and later management uring childhood. The subtypes of CP have long been recogized to have distinctive associations with various neurodevelopental disorders. In terms of anticipatory guidance, early idenification of the specific type of CP has significant implications or the diagnosis and treatment of a wide array of associated eurologic disabilities. Pediatricians managing children receiving arly interventions for motor delay need to discriminate among benign cerebral) hypotonia, developmental coordination disorer, mild motor delay within the broad range of normal, and arious types of CP. The prognosis and management for these ntities differ greatly. Recent data from the United States suggests an increasing revalence of CP. In a multisite, population-based developmenal disabilities network, the reported average prevalence of CP as increased from the relatively stable 2 cases per 1000 to 3.6 ases per 1000, with bilateral spastic forms being the most

Mission Impossible? Blaming Primary Care Providers for Not Identifying the Unidentifiable

* Abbreviation:n ADHD — : attention-deficit/hyperactivity disordernnIn this issue of Pediatrics , Nelson et al report that at 2 years of age, parental, social, and economic factors (including parental education levels below a bachelor’s degree, little or no shared reading at home, food insecurity, and fair/poor parental health), rather than direct developmental evaluation, best predict future low academic achievement scores and high problem behaviors at kindergarten entry.1 Previously, the predictive validity of the Bayley Scales of Infant Development—II performed at 20 months of age to predict IQ scores at 8 years of age has been shown to be only 37%.2 If such comprehensive developmental evaluation using gold-standard assessment measures perform so poorly in predicting learning and behavioral problems at school entry, is it time to stop blaming primary pediatric health care providers for not identifying these children?nnMore than half a century ago, several well-controlled studies demonstrated weaknesses in pediatricians’ ability to assess children developmentally.3,4 Furthermore, in 1987, it was reported that only 28.7% of children who required special educational services in elementary school were identified … nnAddress correspondence to Robert G. Voigt, MD, FAAP, Baylor College of Medicine, Director, Meyer Center for Developmental Pediatrics, Texas Children’s Hospital, 8080 North Stadium Dr, Houston, TX 77054. E-mail: rgvoigt{at}texaschildrens.org